Information Collection

Report Of Injury Experience Of Self-insured Employer

IC 121889 under ICR 197807-1215-003 · OMB 1215-0033.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0033 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	REPORT OF INJURY EXPERIENCE OF SELF-INSURED EMPLOYER	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	LS-274				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 450	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	450	450
Annual IC Time Burden (Hours)	900	900
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.